NINLARO 3 MG CAPSULE (NDC: 63020007901)
2017 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
Plan Name |
Monthly Prem. |
De- duct- ible |
Does Plan Offer Additional Gap Coverage |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Plan’s Avg. Retail Drug Price 30-Day |
Tier Nbr. |
Tier Desc. |
30-Day Prfrd. Pharm |
90-Day Mail Order |
AARP MedicareComplete Mosaic (HMO)
|
$0.00 |
$245 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | 28% | P Q:3 /28Days | $13,634.40 |
Browse Plan Formulary |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P Q:3 /28Days | $12,877.50 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials NYC (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | P | $12,801.80 |
Browse Plan Formulary |
AgeWell New York FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $12,536.60 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$0.00 |
$370 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $12,737.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AgeWell New York LiveWell (HMO)
|
$0.00 |
$370 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $12,536.60 |
Browse Plan Formulary |
Centers Plan for FIDA Care Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P Q:3 /28Days | $12,650.50 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | P Q:3 /28Days | $12,650.50 |
Browse Plan Formulary |
Elderplan FIDA Total Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P | $12,756.10 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,938.20 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,938.20 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,354.40 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,938.20 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P Q:3 /28Days | $12,354.30 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P Q:3 /28Days | $12,927.10 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P Q:3 /28Days | $12,927.10 |
Browse Plan Formulary |
Fidelis Fully Integrated Dual Advantage Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Tier 2 |
0% | n/a | P | $12,801.80 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $13,904.90 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $12,801.80 |
Browse Plan Formulary |
GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P | $12,354.30 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $12,422.50 |
Browse Plan Formulary |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P | $12,422.50 |
Browse Plan Formulary |
ICS Community Care Plus FIDA MMP (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P Q:3 /28Days | $12,650.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:3 /28Days | $13,029.50 |
Browse Plan Formulary |
MetroPlus FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P | $12,801.80 |
Browse Plan Formulary |
PHP Care Complete FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P | $12,423.20 |
Browse Plan Formulary |
SWH Whole Health FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P Q:4 /28Days | $12,354.30 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$0.00 |
$290 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | 27% | P Q:3 /28Days | $13,634.40 |
Browse Plan Formulary |
VillageCareMAX Full Advantage FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P Q:3 /28Days | $12,650.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P Q:3 /28Days | $12,551.70 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $12,861.90 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$7.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,861.90 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$19.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | 26% | P Q:3 /28Days | $13,634.40 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$23.10 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | 30% | P Q:3 /28Days | $13,634.40 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$23.70 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:3 /28Days | $13,634.40 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Plus H3533-021 (HMO)
|
$24.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:3 /28Days | $12,444.50 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$26.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,861.90 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$29.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | P Q:3 /28Days | $12,877.50 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$33.70 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,801.80 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$34.60 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,801.80 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-004 (HMO SNP)
|
$34.60 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P Q:3 /28Days | $12,444.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$34.80 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | P Q:3 /28Days | $13,634.40 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$35.00 |
$230 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | 28% | P Q:3 /28Days | $13,634.40 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$37.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | P | $12,422.50 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$38.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,801.80 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$38.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $12,574.60 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$40.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,801.80 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
|
$40.90 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P | $12,756.10 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$40.90 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P | $12,756.10 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO SNP)
|
$40.90 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | P | $12,756.10 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO SNP)
|
$40.90 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | P | $12,756.10 |
Browse Plan Formulary |
Fresenius Total Health (HMO SNP)
|
$40.90 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,423.20 |
Browse Plan Formulary |
AgeWell New York BeWell (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $12,536.60 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AgeWell New York CareWell (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $12,536.60 |
Browse Plan Formulary |
AgeWell New York FeelWell (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | None | $12,536.60 |
Browse Plan Formulary |
ArchCare Advantage (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P | $12,801.80 |
Browse Plan Formulary |
Centers Plan for Dual Coverage Care (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | n/a | P Q:3 /28Days | $12,650.50 |
Browse Plan Formulary |
Centers Plan for Nursing Home Care (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | P Q:3 /28Days | $12,650.50 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | n/a | P | $12,354.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Fidelis Dual Advantage Flex (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,801.80 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$41.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P | $12,801.80 |
Browse Plan Formulary |
GuildNet Gold (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,354.30 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | P | $12,422.50 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | n/a | P | $12,422.50 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | n/a | P | $12,422.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Liberty Health Advantage Dual Power (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | n/a | Q:3 /28Days | $13,029.50 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | P | $12,422.50 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | P Q:4 /28Days | $12,354.30 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | n/a | P Q:3 /28Days | $13,634.40 |
Browse Plan Formulary |
VillageCareMAX Medicare Health Advantage (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | P Q:3 /28Days | $12,650.50 |
Browse Plan Formulary |
VillageCareMAX Medicare Total Advantage (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | P Q:3 /28Days | $12,650.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
VNSNY CHOICE Medicare Classic (HMO)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P Q:3 /28Days | $12,551.70 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | P Q:3 /28Days | $12,551.70 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | P Q:3 /28Days | $12,551.70 |
Browse Plan Formulary |
Affinity Medicare Passport Select (HMO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $12,801.80 |
Browse Plan Formulary |
WellCare Preferred (HMO-POS)
|
$45.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $12,861.90 |
Browse Plan Formulary |
AARP MedicareComplete Plan 3 (HMO)
|
$66.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:3 /28Days | $13,634.40 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Empire MediBlue Access (PPO)
|
$70.00 |
$260 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | P Q:3 /28Days | $12,927.10 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$78.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,938.20 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$78.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,938.20 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$78.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,354.40 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$78.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,938.20 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$99.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P Q:3 /28Days | $13,277.40 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$109.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | P Q:3 /28Days | $12,551.70 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
|
$226.20 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P | $12,422.50 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$285.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,938.20 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$285.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,938.20 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$285.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,354.40 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$285.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $12,938.20 |
Browse Plan Formulary |